One of the biggest demographic changes, which will have its sociological, economic, political, and health care impact throughout the globe is increase in the proportion of the elderly population. India is one of the countries, which will see a significant increase in the proportion of the elderly in next few decades. One of the major challenges, which is going to arise due to rise in the proportion of the elderly in India is elder abuse.

Earlier, elder abuse was viewed as predominantly a social or family problem, both by the public and professionals. The first scientific literature published in the "British Medical Journal" in 1975 [1] brought this issue to the attention of clinicians. Since then, there has been a steady increase in attention about elder abuse among health professionals, the legal system, and the criminal justice system. [2]

The World Health Organization (WHO) defines elder abuse as "a single, or repeated act, or lack of appropriate action, occurring within any relationship where there is an expectation of trust which causes harm or distress to an older person." [3] The WHO further elaborates that elder abuse can manifest as physical, psychological or emotional, sexual, and financial abuses and can also lead to intentional or unintentional neglect. The neglect can actually lead to isolation, abandonment, and social exclusion. Considering the importance of the issue, the International Plan of Action on Ageing (MIPAA) stated that "Governments be encouraged to develop and fund a National comprehensive strategy and agenda to prevent, detect and intervene in elder abuse." [4]

The prevalence of elder abuse varies from one study to another. It is estimated that about 10% of the elderly in the United States experience some form of elder abuse; however, only a small proportion of these are reported to the protective services. [5] This figure rises to 47.3% among the elderly with dementia. [2] Studies from some of the European countries have reported the prevalence rate to be as high as 61.1%. [2] Studies from India have reported a prevalence rate of about 14%. [2]

Various risk factors have been identified for experiencing elder abuse. Overall, in terms of sociodemographic variables, the findings have been inconsistent but some of the studies have shown that emotional abuse and physical abuse are associated with being separated or divorced, low family income, functional impairment, increasing age, depression, cognitive impairment, and lack of social support. [2],[6],[7] Among all these risk factors, the presence of cognitive impairment has been most consistently shown to be associated with abuse with odds ratios of about 2-4 across different studies. [2] Neglect has been shown to be associated with poor health, being separated or divorced, living below the poverty line, and younger age. [6]

According to WHO, if the primary health care and social service sectors are not well-equipped to identify and deal with the problem, elder abuse will continue to be underdiagnosed and overlooked. [2] However, in busy clinical situations, assessment of elderly patients is often restricted to the assessment of psychopathology and physical comorbidities without much attention given to elder abuse. Data suggest that many a time psychopathology in the elderly, especially depression, can have a reciprocal relationship with the elder abuse experienced by them at the hands of family members and other caretakers. [8],[9],[10] A recent study from Bengaluru, Karnataka, India evaluated 200 elderly patients attending a medical college. According to this study, about one-third of the elderly reported facing abuse or neglect in the form of either verbal abuse, neglect, financial abuse, or physical abuse. There was a statistically significant association between elder abuse and total financial dependence, lack of social support, and depression among the elderly patients. [11] A large sample size, population-based study from the United States suggested a consistent association between depressive features and elder abuse. [8] Depression itself can also lead to abuse and neglect among the elderly. A study from China suggests that feeling of dissatisfaction with life, often being bored, often feeling helpless, and feeling worthless are associated with increased risk of elder abuse and neglect. [9] Elder abuse has also been shown to be associated with posttraumatic stress disorders, premature mortality, higher health care use, especially the use of emergency services, hospitalizations, and readmissions. [2]

As the demographic change is progressing in India, gradually there is a rise in the elderly who require care from the younger generation, which is decreasing in proportion. This is complicated by the fact that an increasing number of urban women are joining the workforce, which has led to the reduction in the manpower available at home to take care of the elderly. This is further complicated by the erosion of value and respect for the elderly, shortage of space in the houses in urban areas, and societal encouragement of "individualism." Due to this, the traditional system of depending on children in old age is changing into a state of financial insecurity and social insecurity among the elderly. [12] There is some evidence to suggest that there is a trend to shy away from the traditional role and responsibility of caring for the elderly and data suggest that the elderly often face abuse, neglect, and violence. [12] Studies over the years from India have shown that many a time emotional, financial, health, and social needs of elderly subjects are not met and as a result, they have feelings of being abandoned, neglected, maltreated, threatened, exploited, and emotionally blackmailed. [12]

Keeping these issues in mind, assessment for abuse for all the elderly presenting to the medical set-ups must be considered. Assessment of elder abuse should include detailed social and sexual histories, comprehensive physical examination, with special attention to the musculoskeletal and genitourinary systems and assessment of cognitive functions. The presence of unexplained signs and symptoms should alert the clinicians for assessment of elder abuse. Providing privacy to the elderly patient during routine clinical examination is often helpful as this helps him/her to open up about his/her psychosocial issues and the care received from others. Every physician/surgeon must evaluate the patient for depression, as this may be an important indicator of elder abuse. [13] Mental health professionals must always rule out abuse and neglect in their elderly patients with depression and dementia. Further, the clinicians must be aware that elderly patients living in the institutional setting are also vulnerable to the experience of abuse at the hands of their caretakers. [14] Various structured instruments are available for screening and assessment of elder abuse. These include Brief Abuse Screen for the Elderly (BASE), Caregiver Abuse Screen (CASE), Elder Abuse Suspicion Index (EASI), Conflict Tactic Scale (CTS), Elder Assessment Instrument (EAI), Health, Attitudes toward Aging, Living Arrangements, and Finances (HALF) Assessment, Indicators of Abuse (IOA) Screen, Suspected Abuse Tool, and Vulnerability to Abuse Screening Scale (VASS). One of the most popular scales, which has been used widely to assess physical, psychological, and sexual abuses is Conflict Tactic Scale (CTS). [2] Clinicians should use these tools for proper documentation for medicolegal purposes too. Detection of elder abuse must be reported to proper legal authorities to prevent further abuse and ensure safety of the patients. Maintenance and Welfare of Parents and Senior Citizens Act, 2007, [15] enacted by the Government of India, has provision for maintenance and welfare of parents and senior citizens. According to this Act, children and heirs of the elderly are obliged to provide maintenance for them by providing monthly allowances. The Act also lays down simple, speedy, and inexpensive mechanisms for the protection of life and property of the elderly. The Act also has provisions for punishment in case the elderly are abandoned.

Clinicians should not get carried away by the accompanying caregivers who seemingly appear to be concerned about the well-being of the patient. Studies, which have evaluated the caregivers of patients with dementia show that caregivers who are more anxious and depressed themselves more often abuse elderly patients. Further, the abuse is associated with spending more time in caring, abusive behavior from care recipients, and a higher caregiver burden. [16] The risk factors identified for being a perpetuator of elder physical abuse include heavy alcohol consumption or use of other substances, history of childhood abuse by father, presence of conflict, depression, living with the victim, and being related to the victim. [17],[18] Elder neglect has been shown to be associated with a high level of anxiety. [17]

However, it is also important to remember that there are large gaps in the research on elder abuse, especially from India. There is a need for a large population-based studies to understand the extent, risk factors, and consequences of elder abuse in this country. Most of the studies across the world are cross-sectional in nature and there is a need for longitudinal study to assess the long-term course and consequences of elder abuse.

United Nations. (2002) Report by United Nations Secretary-General Kofi Annan released at the Second World Assembly on Ageing, Madrid, Spain 8-12 April 2002. Published by the UN Department of Public Information DPI/2264 March 2002.